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I <br />Please otint orfioe. lForm deslaned for use on elite (124tchl twe+hfiter.) EES -4 <br />DTS.C. 00596. 06.64 <br />FormAno•avad.OMRNn 2n5M0'to <br />EPA Form $700-22 (Rev. 3-05) Pre4routeditions are obsolete. DESIGN�ffD FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320,1489 <br />UNIFORMNAZARDOUS jl.GePmtGr1DNurrPer <br />2. Page 1 of <br />3. Emergency Response Phare <br />4. Manifest Tracking Number <br />WASTE MANIFEST `gr) $� �,r%3 <br />1 <br />1-800-424-9300 <br />003779018 JJK <br />K. C— 4Z ye and hiae ig Addrr�s t �+ Generatofs S to Address (d different than ros } <br />Generator's Phone.,'7i— Z <br />P-0. 104- W J 131 <br />6. Transporter 1 Company Name U.S. EPA ID Number <br />Evergreen Environmental Services cAD982413262 <br />7. Transporter 2 Comp" Name U.S. EPA ID Number <br />AddressUS. EPA 10 Number <br />S.Deslgoagl erg�eeri <br />lir <br />6880 SMITH AVENUE <br />NEWARK CA 94560 CAD980887418 <br />Fac ltys Phone: 510-795-4400 <br />9a <br />1 9b. U.S. DOT Desaipdon (including Proper Shl-Wiv Name, Hazard pass, ID Number, <br />10. ConWners <br />11. Total <br />12. Unit <br />13. Waste Codes <br />No. <br />Type <br />HM <br />and Paddng Gmvp (if army)) <br />Quantity <br />Yom. <br />1NON-RCRA HAZARD S WASTE, LIQUID <br />001 <br />Tr <br />G <br />L <br />z <br />2 <br />W <br />t9 <br />3. <br />4. <br />14. Speda) Handing Instn:ctbns and Additional Information <br />PROFILE INVOICE'#. <br />DOT ERG# 171 WEAR PROTECTIVE CLOTHING SALES ORDER# <br />15. GENERATOR•SfOFFEROWS CERTIFICATION: I herebydedare that the contents of M cons:grment are", and aoclrretety de= -bed above by the proper shippN name, and are dassifed, packaged, <br />marked and labeleoacanied, and are to ali respects In proper conddon for transport according to appicable h:ematianal and national govemmentalreguladons. If e)port shipment and I am the Primary <br />Exporter, I certify that the contents of this consignment conform to the terms of The alached EPAAdmo AWgment of Consent <br />I %L that the waste minknIza6a stalemenl Identified In 40 CFR 262.27(a) V. t am a large quantity genera'or) or (b) (tit am a smal qu generator) lj true. <br />ZGe rslOReroes Pdnled/Typed am Signature Month Day Year <br />w-44Jw —a� <br />18. Intemalional ShlpmenG ❑ Impart to U.S. Expwt om U.S. Poul of er. de <br />❑ <br />— <br />Transporter signature (tor exports orgy): Dare lea• U.S.: <br />17. TransporterAc7 orMedgrnent of Recept of Mated&% <br />Transporter1 ,dntedffypedt ame Sgnalure Month Day Year <br />O <br />/ <br />l�C C d <br />Tran dnlWTyped Name Signatur Month Day Year <br />16. Dlsuepanry <br />18a. tYwepanry InrnLaton Space ❑ QcanSty ❑ Type ❑ Residue ❑ Partial Resection ❑ Fdl ReJecli n <br />Mari9esl Reverence Number. <br />18b.AJtemale FadSty(w Generator) U.S. FPA 10 Number <br />LL <br />Fad!Vs Phone: . <br />W <br />18c. Signature ofAtema•:e Facig-ty (or Generanr) <br />Month Day Year <br />z <br />t9. Hazardous Waste Report Management Method Codes (t.e., codes for hazardous waste treatment, disposal, <br />and reMing systems) <br />Uj <br />r <br />20.Oes.!grated Faa;y Ohizr or Operator. Cerflicatfn of receipt of hazardous matedats covered by the mae'.est except as rd_ 1 <br />Printedrr ame11 + Signature Month Day Year <br />rr 0 <br />EPA Form $700-22 (Rev. 3-05) Pre4routeditions are obsolete. DESIGN�ffD FACILITY TO DESTINATION STATE (IF REQUIRED) <br />10320,1489 <br />